Health and Medical History

You may fill out this form online so that it will be ready for you to sign when you come in to our office! If you feel uncomfortable sending this information online, simply print this form, fill it out and bring it to your appointment. Either way filling out this information in advance will expedite your check-in process, we know how valuable your time is.
First Name:
 Last Name:
Birthdate:
 Age:
 Height:
 Weight:
Sex: Male    Female Marital Status:
Employer:
For How Long:
Email Address:
Country:
Street Address:
City:
State:
Zip Code:
Responsible Party (if patient is a minor):
Emergency Contact Person:
Emergency Contact phone number:
Relationship to patient:
Referring Dentist:
Do you smoke?: Yes    No
How much if yes?:
For how long?:
Do you chew tobacco?: Yes    No
How much if yes?:
For how long?:
Are you now under the care of a physician?: Yes    No
For what conditions?:
Have you ever been hospitalized for illness or surgery?: Yes    No
Were there any problems with this? Explain:
Have you had a general anesthetic in a hospital?: Yes    No
Were there any problems with this? Explain:
Has any family member had an adverse reaction to anesthesia?: Yes    No
Do you take any drugs (prescription or non-prescription)?: Yes    No
Please list names and dosages:
Do you have or have you ever had:
Allergy to any drug or medication?: Yes    No
Please list drug name and relation or problem:
Adverse reaction to any anesthetic or anasthesia?: Yes    No
Heart disease or cardiovascular disease?: Yes    No
Heart attack?: Yes    No
Angina?: Yes    No
High Blood Pressure?: Yes    No
Low Blood Pressure?: Yes    No
Rheumatic Fever?: Yes    No
Congenital heart defects or problems?: Yes    No
History of heart disease in your family?: Yes    No
Artificial heart valves, artificial joints, or other implants?: Yes    No
Diseases or surgery of eyes, ears, nose or throat?: Yes    No
Special problems of head, neck, or jaws?: Yes    No
Do you wear contact lenses?: Yes    No
Do you have TMJ or jaw joint problems?: Yes    No
Breathing problems?: Yes    No
Lung or pulmonary disease?: Yes    No
Asthma?: Yes    No
Aspirin Allergy?: Yes    No
Unusual bleeding problems?: Yes    No
Blood disorder?: Yes    No
Blood transfusion?: Yes    No
Immune system suppression or compromise?: Yes    No
Any medication that effects the immune system?: Yes    No
Frequent infections?: Yes    No
Anemia?: Yes    No
Liver disease?: Yes    No
Hepatitis?: Yes    No
Jaundice or yellowing of the skin or eyes?: Yes    No
Diabetes?: Yes    No
Low Blood Sugar?: Yes    No
Ulcers?: Yes    No
Intestinal disease?: Yes    No
Kidney disease?: Yes    No
Thyroid disease?: Yes    No
Seizures or epilepsy?: Yes    No
Steroid or cortisone treatment?: Yes    No
Arthritis?: Yes    No
Cancer treatment?: Yes    No
Chemical dependency?: Yes    No
Psychiatric care?: Yes    No
Family history of inherited diseases?: Yes    No
Any disease, condition, or problem not mentioned above that the doctor should know about?:
WOMEN ONLY:
Date of last menstrual period?:
Are you or may you be pregnant?:
Are you breast feeding an infant?:
Are you taking birth control pills?: